静脉-动脉体外膜肺氧合抢救危及生命的大面积肺栓塞
Life-threatening massive pulmonary embolism rescued by venoarterial-extracorporeal membrane oxygenation.
作者信息
Corsi Fillipo, Lebreton Guillaume, Bréchot Nicolas, Hekimian Guillaume, Nieszkowska Ania, Trouillet Jean-Louis, Luyt Charles-Edouard, Leprince Pascal, Chastre Jean, Combes Alain, Schmidt Matthieu
机构信息
Dipartimento di Anestesia e Rianimazione, Policlinico Universitario A. Gemelli, Università Cattolica Del Sacro Cuore, Rome, Italy.
Medical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre-et-Marie-Curie, Paris 6, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France.
出版信息
Crit Care. 2017 Mar 28;21(1):76. doi: 10.1186/s13054-017-1655-8.
BACKGROUND
Despite quick implementation of reperfusion therapies, a few patients with high-risk, acute, massive, pulmonary embolism (PE) remain highly hemodynamically unstable. Others have absolute contraindication to receive reperfusion therapies. Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) might lower their right ventricular overload, improve hemodynamic status, and restore tissue oxygenation.
METHODS
ECMO-related complications and 90-day mortality were analyzed for 17 highly unstable, ECMO-treated, massive PE patients admitted to a tertiary-care center (2006-2015). Hospital- discharge survivors were assessed for long-term health-related quality of life. A systematic review of this topic was also conducted.
RESULTS
Seventeen high-risk PE patients [median age 51 (range 18-70) years, Simplified Acute Physiology Score II (SAPS II) 78 (45-95)] were placed on VA-ECMO for 4 (1-12) days. Among 15 (82%) patients with pre-ECMO cardiac arrest, seven (41%) were cannulated during cardiopulmonary resuscitation, and eight (47%) underwent pre-ECMO thrombolysis. Pre-ECMO median blood pressure, pH, and blood lactate were, respectively: 42 (0-106) mmHg, 6.99 (6.54-7.37) and 13 (4-19) mmol/L. Ninety-day survival was 47%. Fifteen (88%) patients suffered in-ICU severe hemorrhages with no impact on survival. Like other ECMO-treated patients, ours reported limitations of all physical domains but preserved mental health 19 (4-69) months post-ICU discharge.
CONCLUSIONS
VA-ECMO could be a lifesaving rescue therapy for patients with high-risk, acute, massive PE when thrombolytic therapy fails or the patient is too sick to benefit from surgical thrombectomy. Because heparin-induced clot dissolution and spontaneous fibrinolysis allows ECMO weaning within several days, future studies should investigate whether VA-ECMO should be the sole therapy or completed by additional mechanical clot-removal therapies in this setting.
背景
尽管再灌注治疗实施迅速，但仍有少数高危、急性、大面积肺栓塞（PE）患者血流动力学高度不稳定。其他患者存在接受再灌注治疗的绝对禁忌证。静脉-动脉体外膜肺氧合（VA-ECMO）可能降低其右心室负荷，改善血流动力学状态，并恢复组织氧合。
方法
分析了一家三级医疗中心收治的17例接受ECMO治疗的高度不稳定的大面积PE患者（2006 - 2015年）的ECMO相关并发症和90天死亡率。对出院存活者进行长期健康相关生活质量评估。还对该主题进行了系统综述。
结果
17例高危PE患者[中位年龄51（18 - 70）岁，简化急性生理学评分II（SAPS II）78（45 - 95）]接受VA-ECMO治疗4（1 - 12）天。在15例（82%）ECMO治疗前发生心脏骤停的患者中，7例（41%）在心肺复苏期间插管，8例（47%）在ECMO治疗前接受溶栓治疗。ECMO治疗前的中位血压、pH值和血乳酸分别为：42（0 - 106）mmHg、6.99（6.54 - 7.37）和13（4 - 19）mmol/L。90天生存率为47%。15例（88%）患者在重症监护病房（ICU）发生严重出血，但对生存无影响。与其他接受ECMO治疗的患者一样，我们的患者报告在ICU出院后19（4 - 69）个月所有身体领域均有受限，但心理健康状况良好。
结论
当溶栓治疗失败或患者病情过重无法从手术取栓中获益时，VA-ECMO可能是高危、急性、大面积PE患者的一种挽救生命的治疗方法。由于肝素诱导的血栓溶解和自发纤溶作用可使患者在数天内撤机，未来研究应探讨在这种情况下VA-ECMO是否应作为唯一治疗方法，或是否应辅以其他机械性血栓清除治疗。
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